A ‘near-death’ experience that's good news for patients

For all of its known flaws, the Affordable Care Act has extended coverage to millions
of Americans, and was saved in the U.S. Senate by a slim margin. It's time for Congress
to put aside partisan differences and come together to strengthen and heal Obamacare
instead of trying to bring it down.

In late September, the Affordable Care Act (ACA), otherwise known as Obamacare, came
within a vote or two of being repealed by the U.S. Senate. The bill that would have
repealed it was a radically bad one that deserved to die. Yet this doesn't mean that
Obamacare is safe.

The Graham-Cassidy bill, named after the bill's co-sponsors, Sen. Lindsey Graham (R-SC)
and Sen. Bill Cassidy (R-LA), would have replaced the ACA with an alternative that
turned most of the responsibility for regulating and financing health coverage to
the states, funded in part by block grants from the federal government. Had the bill
passed the Senate, it likely would have also passed the House of Representatives.

Yet Obamacare survived this latest near-death experience, one of many since it became
law in 2017. Senate Majority Leader Mitch McConnell (R-KY) decided not to go ahead
with a planned vote on Graham-Cassidy when it became evident that it would fall one
or two votes short of the 50 votes required to pass, even with Vice President Mike
Pence ready to cast a tie-breaker if needed. Sen. Rand Paul (R-KY) had announced he
was a “no” vote on the bill, and Sen. Susan Collins (R-ME) was expected
to join him in opposition. When Sen. John McCain (R-AZ) then announced he could not
vote for the bill because of concerns that it was being rushed to a vote, Graham-Cassidy's
fate was sealed.

Sen. McConnell's decision to pull Graham-Cassidy meant that 60 votes would soon be
required to pass repeal, since the budget reconciliation measure allowing passage
by a simple majority expired at the end of September. With Democrats unified against
repeal and able to filibuster, and Republicans themselves divided, the ACA appears
to be safe from repeal for at least the remainder of 2017.

And that's good news for patients. For all of its known flaws, like lack of adequate
insurance competition in many markets, the ACA has extended coverage to millions of
Americans. The Graham-Cassidy bill, by contrast, would have taken coverage away from millions. It was fiercely opposed by just about everyone in American health care, from physicians to hospitals to insurers to patient advocacy
groups, with the American College of Physicians among those leading the physician
opposition to the measure. Had it been enacted, Graham-Cassidy would have radically
changed the relationship between the federal and state governments, “the biggest
devolution of federal funding and responsibility to states, ever, for anything,”
noted Larry Levitt, senior vice president of the Kaiser Family Foundation.

How radical was Graham-Cassidy?

It would have replaced the ACA's guaranteed federal funding to help people buy coverage
in the individual market with optional block grants to the states, with very few federal
guardrails on how states might spend their block grant money.

It would have allowed states to eliminate the ACA's prohibition on exclusion of people
with pre-existing conditions, as well as its essential benefit requirements, so that
insurers in many states would again be allowed to charge sick people more for their
insurance, failing what Sen. Cassidy himself had previously referred to as the “Jimmy
Kimmel test.”

States could also decide to permit insurers to again exclude coverage for treatments
that patients need, like chemotherapy, or substance use disorder treatment, or maternity
and childbirth benefits, while reimposing annual and lifetime limits on coverage for
services no longer considered to be essential by a state.

It would have ended Medicaid expansion and capped the federal contribution to Medicaid.
Federal dollars that had gone to Medicaid-expansion states would have been redistributed
to all of the states, resulting in massive losses of money for the expansion states.

Even with block grants, the federal government's contributions to helping make coverage
available and affordable would have been cut by hundreds of billions of dollars over
the next 10 years.

It would have required states to develop an entirely new health care financing system
to replace Obamacare by 2020, or lose all dedicated federal dollars that otherwise
would have gone to the state as a block grant.

Although Graham-Cassidy is dead, President Donald Trump wants Congress to try again,
and an energized core of highly engaged conservative voters and donors will insist
that the party not walk away from its seven-year-old promise of repealing Obamacare.
Keep in mind that almost all of the Republican members of Congress remain fiercely
opposed to Obamacare, and as radical as it was, Graham-Cassidy came within a couple
of votes of becoming law. Graham-Cassidy's policies could come back for another vote,
at another time. Finally, there is nothing to prevent the GOP leadership from approving
a new budget reconciliation measure for FY 2018 or FY 2019 to again allow ACA repeal
by a simple majority vote.

Yet getting to a majority for any ACA repeal or replace bill is anything but simple,
given the strong opposition from physicians, patients, and other health care advocates;
the growing popularity of the ACA and unpopularity of repeal (the latest polls show
that most Americans want the ACA improved, not repealed); and continued divisions
within Republican ranks on what should replace it. Sen. McConnell and Speaker of the
House Paul Ryan (R-WI) may nonetheless try to bring back repeal and replace in 2018,
and if they do, it will once again fall to organizations like ACP to try to stop them.

There is another path available to Congress, one that I hope it will take: Work to
make the ACA better, not blow it up as Graham-Cassidy would have done. Pass bipartisan
legislation to create incentives for health insurers to enter and remain in the individual
markets. Offer consumers in all markets a choice of enrolling in a public option,
like Medicare. Reinsure health plans against adverse selection. Fund outreach programs
to help people enroll.

Obamacare has had more than enough near-death experiences, and although it's (barely)
survived each one, the law is battered and bruised, helping many get coverage but
falling short for others who find the coverage it offers in some markets unaffordable.
It's time for Congress to put aside partisan differences and come together to strengthen
and heal Obamacare instead of trying to bring it down.

Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. ACP Internist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.